What's the biggest mistake you've ever made as a nurse? What did you learn from it?

[Mini-Murse]

If you feel comfortable posting to this thread, awesome. If not, no biggy!

I was wondering what the biggest mistake you've ever made in your nursing career has been. It could have to do with drug dosage or administration, or forgetting something, or even something as simple and innocuous as saying something to a patient or colleague before you could stop yourself!

The reason I think this thread is a good idea is that it shows that we're all human, we all make mistakes, and it will help us learn fro each other's mistakes, especially me and my fellow students, and ease our nerves a bit, so we know that we're not the first to ever take 15 tries to lay a central line or need 5 minutes to adjust an IV drop, but instead we're just part of a larger community who's support we can count on!

To be fair, I'll start.

I was working in a pharmacy, and a patient was prescribed 2.5mg Warfarin. I prepped the script properly, and accidentally pulled a bottle of Warfarin 5mg. I counted out the proper amount of pills, and bottled em up, passed it to my pharmacist for verification. She verified as accurate, and we sold the medicine to the patient. The patient's wife called a few days later and talked to the pharmacist who verified (who was also the pharmacy manager), and we discovered the mix-up. Luckily he hadn't taken for very long, but it terrified me. I could've been responsible for someone dying because I didn't double and triple check the meds. I got reprimanded, and she pharmacist got nothing. (this was also the same pharmacist who misplaced a full bottle of CII meds for 48 hours - she found it behind some loose papers on her desk)

I learned that there is no detail too little to double/triple check in medicine. I learned that it's never acceptable to "get in the zone" and work on reflex, and that every action you take has consequences; some more deadly than others.

[CASTLEGATES]

Recommending we withdraw care on a patient we flogged for about 2 mos, weeping edema, poor cardiac output, exuding odor from browned extremities, infections in every invasive site. We were on the fence, communicating with family but I had enough. Several of us were pushing with ethics and Dr's to call it and withdraw care.

This very man returned, walking into our unit bringing all of the staff a nice lunch tray 6 months later, thanking us for saving his life and never giving up. I quietly slipped off to the bathroom and doubled over, gagging. I couldn't eat! I couldn't believe what just happened. I felt so undeserved of the very air he was breathing. I felt incredibly small.

[brillohead, ADN, RN]

You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?

We did a lab day on it, and we can do them in clinical (Med-Surg III) if our clinical instructor is with us or has signed off on us performing it with just a floor RN with us. However, we were told back at the beginning of the program that the local hospitals have told the nursing program, "We can teach them to put in IVs, what we can't do is teach them to think -- you send us grads who can think, we can teach them to insert IVs here on the job."

[tokmom, BSN, RN]

I'm not saying and yes I learned from it.

[Mulan]

I'm not saying and yes I learned from it.

Smart!

[rita359]

You'd be surprised at some of the things new nurses come out of school and have never done.

My advise is , whenever in clinicals, be sure nurses know you want to at least watch anything interesting even if you can't talk your instructor into letting you do it.

[monkeybug]

You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?

I graduated 15 years ago, and the first IV and the first Foley I ever did were in my preceptorship. So, I hadn't graduated yet, but I didn't get to do them in clinicals. I have acted as a preceptor for nursing students for the last 4 years, and most of my students had many "firsts" while they were with me. I expected that, and made it my goal that by the time they left me (and graduated) they would be proficient in Foleys, IVs, and straight caths.

[monkeybug]

My worst error was actually averted at the last minute (thank you, God). Back when I was a new nurse, we had multidose vials of Potassium on the unit. Our drug cart had a little indentation meant to hold a multidose vial of Normal Saline for flushes. Both medications had a navy blue label. I had a very busy night with moms and babies, and I had 3 saline locks to flush before my shift was over. I pulled up 3 syringes of 3cc of what I thought was normal saline, and headed down the hall. I heard an audible voice say, "Stop, go back, and look at what you did." I did as commanded, and found that I had drawn up 3 syringes of KCl. I threw the syringes in the sharps container, threw the KCl in the garbage, and went in the breakroom for about 15 minutes of absolute hysteria. I then called my nurse manager who handled it very well, she patted me down and convinced me that I didn't need to immdediately resign.

I learned some valuable lessons. Always, always double check medicines. And people can do really stupid things--who puts a multidose vial of potassium in a slot intended for normal saline?! I was thrilled when we no longer mixed our own potassium, as I had lived out how easy it would be to make a mistake.

[Jenni811, RN]

When I was a brand new nurse and still w/ a preceptor, I misread a MAR and gave 25 units of regular insulin instead of the ordered 25 units of long-acting insulin. My preceptor was mad, I called the doctor and had to give the pt a dextrose IV and do hourly finger sticks. I was pretty embarrassed but I think my preceptor could have been a little more involved, she was in space that day!!! Since then, I always triple check insulin dosing!!

Ah, thats sad your preceptor was mad. I just recently started precepting and my orientee made a med error (gave 650 mg tylenol and 2x 5-500 lortab togehter which both contain tylenol.) I wasn't upset, it is more like....What did you learn from this? we wrote up a med event together, called the doc. The patient was totally fine.

[T-Bird78]

I worked at an allergy clinic and had a pt on the highest concentration of his allergy shot serum. He was still in the build-up phase (where they start at 0.05 and titrate up to 0.5 ml). I gave 0.5 ml and pt sat for the required 30 minute wait. A few minutes later another nurse shows me the chart and asked if I gave the dose I wrote down, and that's when I saw the error--I gave 0.5 when the previous dose had been 0.05 and I should have given 0.075. Pt was starting to have an anaphylactic reaction and was being given epi and xopenex nebulizer treatments while being monitored. I apologized to pt and parent (it was a minor child). Pt was okay and stayed for observation an hour and was late being taken to school so pt missed the class field trip that day.

I learned to triple-check EVERYTHING and look back at the past few doses, not just one, and if I can't decipher the handwriting, ask the person who wrote it. We wound up going to an electronic injection record to cut down on trying to determine if it said 0.5 or 0.05 and all agreed to stop using the leading zero.

[brillohead, ADN, RN]

My worst error was actually averted at the last minute (thank you, God). Back when I was a new nurse, we had multidose vials of Potassium on the unit. Our drug cart had a little indentation meant to hold a multidose vial of Normal Saline for flushes. Both medications had a navy blue label. I had a very busy night with moms and babies, and I had 3 saline locks to flush before my shift was over. I pulled up 3 syringes of 3cc of what I thought was normal saline, and headed down the hall. I heard an audible voice say, "Stop, go back, and look at what you did." I did as commanded, and found that I had drawn up 3 syringes of KCl. I threw the syringes in the sharps container, threw the KCl in the garbage, and went in the breakroom for about 15 minutes of absolute hysteria. I then called my nurse manager who handled it very well, she patted me down and convinced me that I didn't need to immdediately resign.

I learned some valuable lessons. Always, always double check medicines. And people can do really stupid things--who puts a multidose vial of potassium in a slot intended for normal saline?! I was thrilled when we no longer mixed our own potassium, as I had lived out how easy it would be to make a mistake.

I'm guessing that mistakes like these were so common that hospitals just started carrying pre-mixed saline flushes to prevent them. Thank goodness your Guardian Angel Nurse was watching over you that day! I hope that when I get around to making my first med error (which I know will happen, I'm human after all!), my G.A.N. will also be watching over me like yours was!

[Mulan]

I heard an audible voice

''

Inside your head or outside of your head?

[RNsRWe, ASN, RN]

Excellent topic.

Lessee.....very early on, in my first months as a nurse, I misread a MAR when I was doing the 24-hour night check (where you reconcile the previous day's MAR with the one printed for the next day, comparing to orders). Somehow I did SOMETHING that would have resulted in a patient getting something like 50 units too much of Lantus! The nurse who had the patient the next day caught the error--BEFORE she gave it, thank heaven--and the NM pointed it out to me when I came in that evening. Scared me to death that it could have been given because of something I did. NEVER did anything like that again, I assure you!

Hmm....I once gave a full tab of Lopressor 25mg instead of a half....which would have been 12.5mg....figured it out an hour later, panicked and did BP checks, did several more that night! He was fine :) What did I learn? That it's STUPID to order a drug that way. Urgh.

And finally....How about hanging the exact same IV atx 3 hours after the last--when it was supposed to be given q6---because I grabbed the wrong one? Was supposed to give two, alternating....oops. I did notify the MD, who didn't think it a big deal, so.....note was made, no one died...this was also in my first year of nursing.....and I learned to READ much more carefully!

Not sure if this post makes me feel like a crappy nurse for making these errors in the first place, or a good one because I've never done anything like them again